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SUBJECT: HMCL223 Clinical Diagnostic Techniques
TYPE: Case Study Assignment Exemplar
TASK:
1. You are required to analyse the following case (including the clinical diagnostic reports): o Comment on your interpretation of disease progression in a holistic manner including
predisposing, excitatory and sustaining factors in the case (consider all important aspects when interpreting the case).
o This interpretation will include comments on all of the pathology tests presented while considering sub-optimal & physiological optimal ranges.
2. After analysing the findings outline at least three further referrals for investigative pathology that is required to support your interpretation of the case.
Generate specific client instructions to the preparation for these diagnostic procedures:
o The type of test that is most relevant to your client & in context of supporting case
interpretation & discussion of suboptimal &/ or physiologically optiomal ranges specific for this client.
o The analyte that is going to be tested.
o Any drugs or supplements that needs to be stopped prior to the test that may impact on the results.
o Any specific instructions prior to testing i.e. time to tst, fasting etc…
o Include the completed Use the pathology referral request forms from Clinipath (WA only) or Healthscope that can be found within the Study Materials section of the HMCL223 LMS homepage. Please complete and include in the Appendix (pathology referral form is not included within the word count).
o Other suppliers or clinical diagnostic techniques – include the support material that outlines cost & delivery.
o If the client requires a referral to a GP to fulfil these referrals then include a referral letter in the Appendix outlinig the tests required & the reason (letter is not included within the word count).
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3. Outline the cost & time involved for the client to fulfil these investigations:
o The pathology referral request forms from Clinipath (WA only) or Healthscope that can
be found within the Study Materials section of the HMCL223 LMS homepage include costings. Consideration of the time to complete the test needs to be discussed.
o If the client requires a referral to a GP to fulfil these referrals then outline the cost & time involved in fulfilling this method of diagnostic procedure (ring or email a local healthcare provider & explore costings in your local area). Please outline the wait time, the cost of the consult & how much will be covered by Medicare.
o Other suppliers of clinical diagnostic techniques outline the collection methods, the cost & the delivery time involed to complete the test & receive theresults. If this is a service provider please ring or email a local healthcare provider & explore costings in your area.
4. Outline the expected results of each test and explain how you will utilize these new diagnostic procedures to reinterpret the case. o Within this reinterpretation utilize specific components / examples from the case that
will support this.
o Outline additional questions and examinations (clinical examination findings) that are required to more clearly evaluate the interpretation of the case. This will require a thorough and comprehensive explanation of the biochemical/ hormonal/ pathological/ naturopathic diagnostic points.
5. Conclude with an analysis of the relevance of these interventions versus client compliance & create a definitive statement as to why or why not these tests are required. o Prioritize these referrals by considering the requirement to the management of the
case, if the investigation can be thoroughly explored with the questions & examinations outlined in the previous point. Consider the client’s outlay (time & money) to comply with these requests.
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Case Study
Female: 37 years old
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Pathology
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1. Case Analysis
Well Developed
(15-11 marks)
Developed
(10-6 marks)
Poorly Developed
(5-0 marks)
Case was analysed & interpreted
accurately & concisely:
In a holistic manner Explored disease progressions
within the context of predisposing, excitatory & sustaining factors.
All important aspects were considered
All of the clinical diagnostic reports were discussed within the context of the case & the relevant symptoms presenting.
Clinical reports were discussed within the context of sub-clinical analysis & /or physiological optimal ranges.
Case was mostly analysed &
interpreted in:
In a holistic manner Moslty explored disease
progressions within the context of predisposing, excitatory & sustaining factors.
Most important aspects were considered
Most of the clinical diagnostic reports were discussed within the context of the case & the relevant symptoms presenting.
Moslty the clinical reports were discussed within the context of sub-clinical analysis & /or physiological optimal ranges.
Case was analysed & interpreted
intermittently or missing:
Symptomatlically & not in a holistic manner
Not explored or missing 1 or more aspects of predisposing, excitatory & sustaining factors.
Some or none of the important aspects were considered
Clinical diagnostic reports were not or poorly discussed within the context of the case & the relevant symptoms presenting.
Clinical reports were not discussed or poorly discussed within the context of sub-clinical analysis & /or physiological optimal ranges.
2. Referrals
Well Developed
(15-11 marks)
Developed
(10-6 marks)
Poorly Developed
(5-0 marks)
Client instructions: accurate &
concise information on:
Type of test, relevance to the client & in context of supporting case interpretation & discussion of sub-optimal &/ or physiologically optiomal ranges specific for this client.
The analyte & specific instructions to preparing for the tests including the use of drugs / supplements.
Three completed pathology referral request forms / other supplier request forms/ GP referral letter (in Appendix)
Client instructions: mostly accurate &
concise information:
Type of test, relevance to the client & in context of supporting case interpretation & discussion of sub-optimal &/ or physiologically optiomal ranges specific for this client.
The analyte & specific instructions to preparing for the tests including the use of drugs / supplements.
Three completed pathology referral request forms / other supplier request forms/ GP referral letter (in Appendix)
Client instructions: intermittent or
missing information on:
Type of test, relevance to the client & in context of supporting case interpretation & discussion of sub-optimal &/ or physiologically optiomal ranges specific for this client.
The analyte & specific instructions to preparing for the tests including the use of drugs / supplements.
Three completed pathology referral request forms / other supplier request forms/ GP referral letter (in Appendix)
3. Client Compliance Consideration
Well Developed
(10-7 marks)
Developed
(6-4 marks)
Poorly Developed
(3-0 marks)
Client Cost & Time Analysis
includes:
Clearly & concisely evaluated & quantified the cost & time involved in the requested referrals / investigations.
Client Cost & Time Analysis
includes:
Broadly evaluated & quantified the cost & time involved in the requested referrals / investigations.
Client Cost & Time Analysis includes:
Intermittent or missing evaluated & quantified the cost & time involved in the requested referrals / investigations.
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4. Expected Results
Well Developed
(10-7 marks)
Developed
(6-4 marks)
Poorly Developed
(3-0 marks)
Analysis of expected results
thoroughly & concisely explored:
Diagnostic procedures are in context to the case (examples given) which clarifies relevance of use.
Supportive additional questions & examinations are explained in biochemical/ hormonal/ pathological & or naturopathic diagnostic points with a clear link to exploring the theory of case analysis explored with the diagnostic procedure.
Analysis of expected results mostly
explored:
Diagnostic procedures are in context to the case (examples given) which clarifies relevance of use.
Supportive additional questions & examinations are explained in biochemical/ hormonal/ pathological & or naturopathic diagnostic points with a clear link to exploring the theory of case analysis explored with the diagnostic procedure.
Analysis of expected results
intermittently or did not explore:
Diagnostic procedures are in context to the case (examples given) which clarifies relevance of use.
Supportive additional questions & examinations are explained in biochemical/ hormonal/ pathological & or naturopathic diagnostic points with a clear link to exploring the theory of case analysis explored with the diagnostic procedure.
5. Conclusion
Well Developed
(5-4 Marks)
Developed
(3-2 Marks)
Poorly Developed
(1-0 Marks)
Conclusion clearly & concisely
analyses:
Prioritization of the referrals by considering the findings as pivotal to the management of the case.
If the diagnostic technique could have gained similar outcomes from more rigorous case investigations (questioning & clinical examination findings)
Consider the client’s outlay (time & money) to comply with these requests.
Closing statement as to the requirement of the aforementaioned diagnostic procedures.
Conclusion mostly analyses:
Prioritization of the referrals by considering the findings as pivotal to the management of the case.
If the diagnostic technique could have gained similar outcomes from more rigorous case investigations (questioning & clinical examination findings)
Consider the client’s outlay (time & money) to comply with these requests.
Closing statement as to the requirement of the aforementaioned diagnostic procedures.
Conclusion considers some points of:
Prioritization of the referrals by considering the findings as pivotal to the management of the case.
If the diagnostic technique could have gained similar outcomes from more rigorous case investigations (questioning & clinical examination findings)
Consider the client’s outlay (time & money) to comply with these requests.
Closing statement as to the requirement of the aforementaioned diagnostic procedures.
No conclusion evident
Referencing & Word count
Well Developed
(5 marks)
Poorly Developed
(0 marks)
Within word count & correctly referenced using Harvard
Over word count & / or Incorrect use of Harvard & / or 1 or more references missing
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HMCL223 Student Assignment Exemplar
CONTENTS
Case outline, disease progression theory of pathology ............................................ 14
Pathology Results .................................................................................................... 15
Investigative Pathology Further Referrals ................................................................ 16
Liver Function Test ............................................................................................... 16
Prognosis, Reinterpretation, Intervention .......................................................... 17
Homocysteine ....................................................................................................... 18
Prognosis, Reinterpretation, Intervention .......................................................... 18
Complete Thyroid Profile ...................................................................................... 19
Prognosis, Reinterpretation, Intervention .......................................................... 20
Other Investigations .............................................................................................. 20
Conclusion ............................................................................................................... 21
REFERENCE LIST................................................................................................... 22
Appendix .................................................................................................................. 23
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Case outline, disease progression theory of pathology
Appendix provides a mind map outlining these.
A 37-years-old female, financial consultant, presents with hypertension and 30kg weight
gain within a year. She is stressed, anxious, possibly depressed, has a poor nutrient diet,
migraines, deep vein thrombosis (DVT), low libido, a history of preeclampsia, gestational
anaemia, cesarian, depression, smoking and hysterectomy. A familial predisposition to
hypertension and cancer exists.
Predisposing Factors Sustaining Factors Excitatory Factors
Smoking Stress Stress
Lack of exercise and sedentary life
Malabsorption Anxiety
Stressful job Food Allergies: yeast Depression
Hormonal imbalances Lack of exercise and sedentary life
Insomnia
Coagulation, heart & blood vessel disorders (DVT)
Diet Fatty food intolerance
Inconsistent weight. Altered HPAT-axis or HPG-axis
Under-nutrition
Familial history of hypertension
Hypertension
Table 1 - Predisposing, sustaining, excitatory factors to hypertension and obesity
Obesity can result in hypertension (McCance et al. 2010, p.1152). Hypertension, smoking
and obesity, increased her risk to develop DVT (27yr; on anticoagulants since) (Douketis
2014). With increased stress, prior intense exercise, decreased rest and unmanaged
stressed response, fatigue, along with her sustained hypertension, her menstruation
disorders may have been due to dysregulating one of the hypothalamic–pituitary–
adrenal/thyroid/gonadal axes, which excite and sustain obesity, fatigue any psychological
symptoms. Physical inactivity, along with sleep deprivation, depression, anxiety and stress
have contributed to her excess weight gain and hypertension (Akabas et al. 2012, pp.18-
19,28-30). Physical inactivity and poor diet increase susceptibility to Non-alcoholic-fatty-
liver-disease (NAFLD) (Day 2002). Anticoagulants, dehydration, anxiety, stress,
hypertension, fatigue and hormonal irregularities contribute to migraines (associated with
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NAFLD), while symptoms are exacerbated by low nutrient intake and are correlated with
cardiovascular and nervous system symptoms, palpitations, breathlessness, panic attacks
and low energy (Celikbilek et al. 2014; Mayo Clinic 2013; Mayo Clinic 2015). Hypertension
can result in palpitations, shortness of breath and headache (Walker et al. 2014,
pp.607,609).
Medically Diagnosed
Currently Previously Upon examination
DVT, Hypertension Post-natal depression, hysterectomy
(intact ovaries), two C-sections, pre-
eclampsia
BMI: 33.35 -
obesity class 1
Table 2 - Medically Diagnosed
Pathology Results
Haemoglobin levels are all within range except for her MCHC which may be sub-optimally
low, perhaps due to anaemia and present as fatigue, but this alone is insufficient as MCV,
haemoglobin and haematocrit are within range (Pagana & Pagana 2014, p.447; Vaucher
et al. 2012).
WBC are within range. Signifying decreased possibility of inflammatory disorders,
metabolic disorders, paracytic infections or allergic reaction, but alone aren’t definitive
(Pagana & Pagana 2014, pp.526-532).
Lipid profile tests indicate total cholesterol, LDL, triglycerides and HDL are within range
and according to calculations based on Pagana & Pagana (2014, p.156) she has a 1% 10-
year CHD risk, contesting metabolic syndrome, dyslipidemia and CHD (Akabas et al.
2012, p.16; Kazaks & Stern 2013, p.54). Prior elevated LDL and total-cholesterol may be
attributed to hypothyroidism, pregnancy, chronic liver disease, Cushing syndrome (Walker
et al. 2014, p.453). With a history of DVT, LDL target should be below 2.0mmol/L.
Table 3 - Ratios
Ratios
LDL/HDL 1.6 HDL/LDL 0.59 Total-cholesterol/HDL 3 CHD Risk Low
The phase in menstruation cycle of the collected FSH and LH sample isn’t identified.
Ovulation day isn’t identified due to hysterectomy. FSH is within range. Only if collected
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during the luteal phase is LH within range. A LH/FSH ratio of less than 2 is normal,
signifying smaller degree of PCOS implication (Banaszewska et al. 2003). Low LH could
indicate thyroid disorders, stress or malnutrition, while increased LH may indicate PCOS,
low estrogen (Pagana & Pagana 2014, p.350; Poppe et al. 2007).
TSH is with range and therefore doesn’t directly implicate thyroid disease related
symptoms. This alone doesn’t rule out thyroid disorder associated symptoms, such as
obesity, history of menstruation disorders, dry skin, palpitations, anxiety, depression,
insomnia; as T4 T3 can be within or out of range and thyroid autoantibodies still present
(Degner et al. 2014; Kronenberg 2008, pp.378-384,386). Prior suboptimal TSH may be
due to early autoimmune thyroiditis (transient thyrotoxicosis) (Kronenberg 2008,
p.364,390).
Fasting glucose levels are within range, signifying absence of hypoglycemia, diabetes
mellitus, metabolic syndrome or Cushing’s disease (Pagana & Pagana 2014, p.256).
Excess thirst and sweat may have other sources. Though insulin resistance may maintain
pancreatic beta-cell secretion and normal glucose levels her blood glucose levels are
within range (Kyrou et al. 2010, pp.209-210).
Investigative Pathology Further Referrals
This section provides diagnostic tests required to assess client pathophysiology and
establish a baseline prior to treatment, to which we can reassess progress after 3-4
months of treatment by retesting and measuring outcomes against goals and proving
client reflection. Baselines are the analytes for each diagnostic investigation.
LIVER FUNCTION TEST
Analyte Expected result
Aspartate aminotransferase (AST)
Moderately Increased
Alkaline phosphatase (ALP) Within range (or possibly elevated)
Alanine aminotransferase (ALT)
Increased
Total Bilirubin Increased
Albumin Decreased
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Gamma-glutamyltransferases (GGT)
Increased
Total Protein Decreased
Table 4 - LFTs
Reasoning: Due to anticoagulants, fatty food intolerance, nausea, vomiting, bruising,
impaired sulphation pathway, amalgam fillings (contain mercury) migraines, fatigue
(sluggish liver due to toxic load, decreased blood oxygen carrying capacity) and
impairment from smoking (also increases ammonia), alcohol, dyspnoea, sleep
disturbances and obesity which will help assess function and structure of the liver
(Celikbilek et al. 2014; Hechtman 2012; Walker et al. 2014, pp.959-961; Pagana & Pagana
2014, pp.39-40,47-49,119-126,246-248,424-432).
Instructions
Specimen/Method Preparation Avoid on day of test and day before
Serum blood test from vein in arm obtained in the morning (8:00am)
Overnight (>8-hour) fasting required
Analgesics, caffeine, NSAIDs, diuretics, antibiotics, vitamins and supplements
Caution Daily anticoagulant dose should be administered after blood specimen collection and greater than 12-hours before;
Table 5 – Instructions (Pagana & Pagana 2014, pp.40,48-49,119-126,247,424-432)
Prognosis, Reinterpretation, Intervention
Due to reasoning above, these enzymes are expected to be elevated. This will indicate
increased circulating liver enzymes, which can signify fatty liver deposits, impaired
detoxification, cirrhosis, increased toxins and inflammation (McCance & Huether 2014,
p.1413,1460-1461; Pagana & Pagana 2014, pp.39-40,47-49,119-126,246-248,424-432).
Characteristic of visceral fat is the release of adipokines and fatty acids (FA) to the liver,
which then enters circulation, impacting hepatic function, which increases liver FA deposits
resulting in fatty liver (NAFLD) and possibly insulin resistance and hypoglycemia
(Grossman & Porth, 2014, p.1253). Mitochondrial dysfunction results in increased reactive
oxygen species or extensive lipid peroxidation in response to an increased hepatic supply
of free-FA due to obesity resulting in non-alcoholic-steatohepatitis, oxidative damage and
inflammation (cytokine production) contributing to insulin resistance (Day 2002). Lack of
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exercise and diet increase susceptibility to NAFLD/NASH and greatly influence FA supply,
fat distribution and oxidative stress (Day 2002).
Weight loss via dietary intervention (i.e. anti-inflammatory diet) and exercise, has shown to
resolve liver biochemistry and reduce liver size, fatty liver deposits, fibrosis and
steatohepatitis (Kronenberg 2008, p.1573; Hickman et al. 2002).
HOMOCYSTEINE
Reasoning: Due to palpitations, shortness of breath, fatigue, swollen feet, cold
extremities, sweat, insomnia, hypertension, obesity, DVT, physical inactivity, smoking,
malnutrition, increased LDL and total-cholesterol which increase her risk for
atherosclerosis, coronary, peripheral and cerebrovascular disease, therefore it is essential
to differentiate between these “red-flag” conditions and refer if necessary (Walker et al.
2014, p.581).
Instructions
Specimen/Method Preparation Avoid on day of test and day before
Serum blood test from vein in arm obtained in the morning (8:00am)
Overnight (>12-hour) fasting required
NSAIDs, anticonvulsants, antiepileptics, theophylline, nitrous oxide, folic acid, OCP, tamoxifen, smoking, vitamin B’s
Table 6 - Instructions: (Pagana & Pagana 2014, p.303)
Prognosis, Reinterpretation, Intervention
Due to above reasoning homocysteine levels may be elevated. This could indicate
cystinuria, malnutrition, Vitamin B6, B12 or folate deficiency; cardiovascular,
cerebrovascular or peripheral vascular disease, since it contributes to arterial and venous
thrombosis and atherosclerosis (Kumar et al. 2010, p.122; Pagana & Pagana 2014,
pp.303).
Folate and Vitamin B12 are required for the conversion of homocysteine to methionine and
Vitamin B6 is required for metabolising homocysteine to cysteine, therefore reducing
circulating homocysteine levels; while increased homocysteine may interact with
dyslipidemia and hypertension increasing coronary risk (Gropper & Smith 2013, p.201-
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202; McCance & Huether 2014, p.989,1049). Due to these deficiencies phase-II
detoxification may be compromised as homocysteine is an intermediate in methyl and
sulfur group metabolism (Pizzorno & Murray 2013, p.496).
Intervention via combination of folate, Vitamin B12 and B6 should correct homocysteine
levels and remethylation pathways, improve phase-II detoxification and possibly reduce
CHD risk (Pizzorno & Murray 2013, p.496,500-501).
COMPLETE THYROID PROFILE
Analyte Expected Results
TSH As presented or suboptimal upper-end
FT4 Out-of-range below; Sub-optimal low;
FT3 Out-of-range below; Sub-optimal low;
rT3 Determined by T4 to T3 conversion; Nutrient deficiencies
Thyroid Autoantibodies: Antithyroglobulin Antibody (TgAb)
Elevated
Thyroid Autoantibodies: Antithyroid Peroxidase Antibody (TPOAb)
Elevated
Table 7 Thyroid Profile (Pagana & Pagana 2014, p.102-105, 486-489,497-500,506-508)
Reasoning: To rule out Hashimoto thyroiditis and due to her symptoms: weight gain, prior
menstruation disorders, dry skin, palpitations, anxiety, depression, swelling, fatigue, cold
peripheries, insomnia, decreased appetite (Degner et al. 2014; Kronenberg 2008,
pp.364,378-384,386,390-391; Walker et al. 2014, p.741).
Instructions
Specimen/Method Preparation Avoid on day of test and day before
Serum blood test from vein in arm (preferably morning)
No fasting required Avoid these drugs on the day of the test and previous day: aspirin, anticoagulants, fibrinolytic, heparin, beta-blockers, antibiotics, OCP, estrogens, androgens, furosemide, opioids, anti-seizure.
Caution: Daily anticoagulant dose should be administered after blood specimen collection and greater than 12-hours before;
Table 8 - Instructions: (Pagana & Pagana 2014, p.102-105, 486-489,497-500,506-508)
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Prognosis, Reinterpretation, Intervention
Due to above reasoning TgAb and TPOAb could be elevated and may accompany
hypothyroid symptoms (Kronenberg 2008, p.387). Prior transient thyrotoxicosis may have
led to thyroid cell destruction (Kronenberg 2008, p.390). TgAb, TPOAb and activate T-cells
destroy thyroid cells and target thyroid TSH-receptors destroying these minimising TSH
thyroid stimulatory effect (Crowley 2013, p.682). Feedback mechanisms may increase
TSH and lower thyroid hormones (Crowley 2013, p.682). TPOAb can cross the blood brain
barrier leading to inflammation and pathogenesis of anxiety, depression and mood
disorders (Degner et al. 2014). Decreased carbohydrate, protein and lips metabolism due
to decreased thyroid hormones reduce basal metabolic rate leading to weight gain
(Tortora & Derrickson 2012, p.698). Permeation of mucopolysaccharides into tissues can
result in dry skin, oedema, fluid retention and anemia (Walker et al. p.743). Cholesterol
levels may increase due to protein under-stimulation, and reduced glucose and FA
utilisation for ATP production (Tortora & Derrickson 2012, p.699). Aminotransferases may
be raised due to impaired clearance (Kronenberg 2008, p.380).
Intervention with selenium, iodine, supplementation will improve thyroid function, increase
and hormones, protect thyroid tissue, improve T4 to T3 deiodination, decrease thyroid
autoantibodies and therefore improve pathophysiological function denoted above leading
to weight loss and decreased symptom (Kohrle 2013).
OTHER INVESTIGATIONS
Baseline Hormone Profile (female) (serum). This will help obtain significant hormone
imbalances that may be contributing to her weight gain (i.e. PCOS), low libido, disturbed
sleep and point to an aetiology for her prior menorrhagia and dysmenorrhea (Reid &
Evans 2011, p.71).
Adrenal Hormone Profile test to assess her adrenal function due to her ongoing stress,
anxiety, insomnia, headaches, depression and fatigue as increased cortisol may lead to
adrenal hypertrophy or adrenal exhaustion, while reduced DHEA-S also results in fatigue,
weight gain and impaired cognitive function (Reid & Evans 2011, p.93).
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Conclusion
Obesity can trigger hypertension and many of her symptoms, including psychological. The
hypothesis was that there is a main aetiology governing this pathology. Dysregulation of
the hypothalamic–pituitary–adrenal/thyroid/gonadal axes were investigated as sources of
her presenting case. While differentiation is crucial as there is a crossover amongst these
axes defining the variables of elevated TgAb and TPOAb gave justification to presenting
complaints. Therefore, complete thyroid profile was applicable to assess, antibodies, HPT-
axis dysregulation and manage the client respectively.
Due to parameters involving her history and symptoms (see Homocysteine section), of
impact of cardiac health or CHD risk assessment via pathology test, such as CRP,
fibrinogen or homocysteine would be essential. Therefore, homocysteine could provide
markers for these conditions but also provide a route for naturopathic therapeutic planning
and co-management (referral).
Liver function tests were chosen due to obesity, mercury exposure and allergies which
may have been impacted liver functions. Assess of the liver would guide intervention by
also focusing on supporting the liver function, detoxication, protecting it and minimising
insulin resistance.
Client compliance, in term of cost and time were considered when selecting diagnostic
investigations. All tests can be performed on the same morning. A referral has also been
appended.
Referral prioritisation Diagnostics Reasoning
1st Homocysteine Hypertension and Cardiovascular Health
2nd Thyroid Hormone Profile Hypertension, Weight Gain and relative symptoms
3rd Liver Function Test Impact of obesity on liver function and physiology
Possible further investigations
4th Adrenal Hormone Profile Adrenal cortex impact and contribution to disease state
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5th Baseline Hormone Profile Prior cause of menorrhagia and dysmenorrhoea
Table 9 - Referral prioritisation
REFERENCE LIST - removed